Multiplex PCR testing requires a robust multi-disciplinary strategy to effectively manage identified cases of chlamydial conjunctivitis

Introduction

Chlamydial conjunctivitis most commonly presents as a chronic unilateral follicular conjunctivitis, occasionally with atypical features such as peri-limbal infiltrates. Patients with viral conjunctivitis typically attend primary care or ophthalmology with symptoms unresponsive to topical antibiotics. Presumed viral conjunctivitis is not normally investigated for its aetiology unless the symptoms have had a prolonged duration of >2 weeks or if there are atypical clinical features.^1–3

Chlamydial conjunctivitis rates have been shown to correlate with the recent 7% rise in genital Chlamydia infections (over 217,000 reported in the UK in 2009).^1,4–6 Best management of chlamydial conjunctivitis should include specialist sexual health input, to ensure detection and treatment of genitalChlamydia, exclusion of other STI co-infections, completion of partner notification and safer sex advice to prevent re-infection.^1,3,5 Genito-urinary carriage of Chlamydia trachomatis D-K is often asymptomatic, but can cause symptomatic infection including conjunctivitis in a sexual partner.^4,7,8 The serovars A–C are responsible for trachoma and do not cause genital infection. ⁹

In April 2007, the West of Scotland Specialist Virology Centre upgraded their routine assay for eye swabs to an in-house quadriplex polymerase chain reaction (PCR) assay for Adenovirus, Varicella zoster, Herpes simplex and Chlamydia trachomatis. This was intended to improve the efficiency and accuracy of sample processing. Multiplex PCR assay has been shown to be quick, cost-effective, sensitive and specific.^10–14 However, this quadriplex test meant that eye patients could be unknowingly screened for a sexually transmitted infection and soon there was a complaint from a patient about this. Although the complaint raised awareness of the issue, anecdotal concerns remained about poor sexual health attendance for Chlamydia-positive patients identified in eye casualty. We wished to evaluate the impact of this new test and address any other issues indirectly created following the routine implementation.

Methods

Twelve months after the new quadriplex PCR assay was introduced, we performed a retrospective review of the clinical impact of this method of testing, prior to any improvement in the pathway. This audit identified all Chlamydia-positive eye swab results processed at the Specialist Virology Centre from May 2007 to April 2008. We then selected Chlamydia-positive results in adults, which had originated from the Glasgow Eye Casualty Service and reviewed the available clinical notes. The chosen audit standards included documentation of the potential implications of testing, the patient being appropriately contacted following positive results, attendance at sexual health/general practitioner (GP) for assessment, appropriate treatment, complete sexual health screen and sexual contact tracing. Our aim was to compare the recorded clinical management with these locally chosen standards. Our literature search did not identify any articles documenting these problems in ophthalmic practice or any published recommended standards.

The Glasgow Eye Casualty service is based at Gartnavel General Hospital, Glasgow, UK. The West of Scotland Specialist Virology Centre processes viral eye swabs from Greater Glasgow, Clyde and other regions in the West of Scotland. The Sandyford Initiative provides specialist sexual health services to the whole population of NHS Greater Glasgow and Clyde (approx. 1 million) and supports all practitioners managing genital Chlamydia cases through a Shared Care system.

Results

The Specialist Virology Centre processed 1914 eye swabs in the year following the introduction of the multiplex PCR assay, resulting in 76 Chlamydia PCR positive eye swab results, a positive proportion of 4%. There were 20 children <1-month-old with vertically acquired Chlamydia among the 25 patients who were aged <16 years. Fifty-one patients were 16 years or older. Twenty-six patients were female and 25 male. The average age of this group was 23 years (range 16–68). About 80% (41 out of 51) of the patients were <25 years of age. These population demographics mirror the national average with similar predominance in the 16- to 25-year-old age group.^1,4,5,15

Concerns regarding the multiplex assay revealing dual conjunctival pathology were alleviated, as none of these cases had concurrent positive results. Such situations are rare, but case reports have highlighted the potential for chronic conjunctivitis to have more than one cause. ¹⁶

Twelve of the 51 adults originated from the Glasgow Eye Casualty and these were subjected to our audit standards. We were able to obtain nine sets of eye casualty notes. All patients had presented with unilateral follicular conjunctivitis of >2 weeks duration, which had not settled with topical antibiotics (see Table 1 for results). Only three patients (25%) achieved our chosen audit standards. As it was the clinicians’ expectation that these patients would have subsequently attended sexual health services, we sought reasons for this poor outcome.

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Table 1.

Table of retrospective audit results for chlamydial conjunctivitis from May 2007 to April 2008 evaluating the impact of multiplex PCR testing.

Audit standard	Results
Adults with Chlamydia-positive swabs sent from eye casualty	12 patients
Obtainable eye casualty notes	9 out of 12 patients
Evidence of pre-swab consent	0 out of 9 patients
Patient contacted post-result	4 out of 9: directly contacted
3 out of 9: GP informed as not contactable after 1 week
2 out of 9: no documentation regarding follow-up
Initiation of treatment	4 out of 9: by ophthalmologist
2 out of 9: deferred by ophthalmologist to sexual health
2 out of 9: already treated by GP
1 out of 9: no documentation
Attendance at sexual health	4 out of 12 patients
Screening	2 out of 4: Chlamydia-positive on urine testing
1 out of 4: Chlamydia-positive on vulvo-vaginal testing
1 out of 4: no other evidence of Chlamydia infection
Contact tracing	3 out of 4: seen by sexual health advisor
1 out of 4: no documentation

Discussion

There was no documentation in any of the ophthalmology notes regarding the implications of testing. This had led to a formal complaint from the family of a young teenaged patient who attended eye casualty and was found to be Chlamydia-positive. This unfortunate scenario was the main catalyst to this study. Poor communication of results to patients was being compounded by poor effectiveness of referral to sexual health services for assessment and subsequent contact tracing. The results of the audit were then presented and discussed by all interested parties in order to develop a protocol to improve the service (Table 2).

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Table 2.

Summary table of service changes to create shared care network to appropriately manage chlamydial conjunctivitis identified in the eye casualty.

Problem	Reason for change	Change	Benefit
No informed consent for testing	Complaint	Discussion of implications and consent gained	Better awareness of potential outcome
Poor communication	Complaint	Patient information leaflet	Explanation of tests, their purpose and significance
Lack of availability of case records	Difficulty with follow-up	Improve filing of casualty notes with patient records Ensure accuracy of source of tests Sexual health advisor receives copy of all positive results	All patients liaised with advisor concerning condition and its management
Unable to contact patient	Positive results not acted on	Sexual health advisor receives copy of all positive results Result has advice statement suggesting sexual health referral Check accuracy of patient contact details	More avenues to contact patient GP contacted by advisor if patient is not contactable
Some patients not treated and others treated incompletely	Poor compliance with treatment and follow-up	Treatment to be initiated by GP or sexual health team	Encourage attendance at sexual health clinic to obtain treatment
Uncertain follow-up	No contact tracing Other genito-urinary conditions may be neglected	Pathway referral via sexual health advisor, who coordinates follow-up with GP	Ensure appropriate assessment and treatment of patient and contacts

These issues were addressed by the following three strategies:

Ensure informed consent for testing: all clinicians (including Ophthalmologists) should obtain appropriate consent for testing by informing patients of the routinely tested organisms from eye swabs and the associated implications. All tested patients should receive a Patient Information Sheet explaining the reason for the test, the potential outcomes and details of the Sandyford services. This should reduce any future conflict or shock that the investigation of a minor eye problem can result in the diagnosis of a sexual transmitted infection.

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Figure 1.

Example of a chlamydial conjunctivitis positive result with advice from laboratory regarding onward referral to sexual health.

Conclusion

We have identified a rate of 4% Chlamydia-positive cases in all swabbed cases of presumed viral conjunctivitis. This represents a potentially undiagnosed cohort of individuals with a sexually transmitted infection. Managing chlamydial conjunctivitis in eye casualty requires a thoughtful and encompassing approach as patients do not expect the identification of such an infection in this setting. A novel quadriplex PCR test has contributed to the development of a multi-disciplinary approach to address all the issues involved in the effective management of chlamydial conjunctivitis. This has been due to improved communication and formalised protocols between virology, ophthalmology and specialist sexual health, with a central point of contact through a designated sexual health advisor. Similar new laboratory testing strategies or algorithms may require other cross-discipline working in the NHS as a whole.